Substituted Interests and Best Judgments: An Integrated Model of Surrogate Decision Making

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Making decisions on behalf of patients without decision-making capacity remains challenging, especially at the end of life. Under the current US model, formal written or oral directives expressing patient wishes for future care are preferred. Lacking that, surrogates are instructed to provide substituted judgments, choosing what the patient would have chosen. If the patient never had capacity or the patient's preferences are unknown, a decision should be made in the patient's best interests. This hierarchical model of separate standards, however, does not always reflect clinical reality or the interests of patients and families. In this commentary, we propose an alternative approach: the substituted interests model.

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